ACUTE ABDOMEN: AN OVERVIEW. Dr. S. Nag, M.D. (Ob/ Gyn) Dr. N. Bhattacharya, M.D., M.S., D.Sc., FACS (USA) Vidyasagar Hospital Kolkata

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1 ACUTE ABDOMEN: AN OVERVIEW Dr. S. Nag, M.D. (Ob/ Gyn) Dr. N. Bhattacharya, M.D., M.S., D.Sc., FACS (USA) Vidyasagar Hospital Kolkata

3 Abdominal plain films are essential for accurate assessment of the acute abdomen. In many cases, they may confirm the presence of a perforated viscus, colonic obstruction, or other abnormality requiring immediate surgical intervention. Alternatively, they may suggest relatively benign disease and help avoid unnecessary operations in these patients. In either case, emergency room physicians should benefit greatly from a systematic approach to the plain film diagnosis of the acute abdomen.

5 Acute abdominal disorders are common reasons for consultation at the emergency department. The diagnosis of all acute abdominal disorders begins with a careful history and physical examination. When appropriate, the clinical examination should be supplemented by conventional plain abdominal radiography. Gastrointestinal perforation and obstruction are very commonly encountered in the diagnosis of acute abdomen. Plain abdominal radiographs are the initial diagnostic methods of choice. In some circumstances, ultrasonography and CT may be valuable for the evaluation of the cause of abdominal disorder.

8 Incidence of specific causes of acute abdominal pain in children Intussusception Three in every 1000 live births Appendicitis Four in every 1000 children aged 5-14 years each year Crohn's disease One in every children

9 Only a third of children with appendicitis will have classic symptoms The appendix does not grumble--it screams or remains silent

11 Causes of acute abdominal pain in children Common causes* Appendicitis * Non-specific abdominal pain

12 , Uncommon causes Meckel's diverticulitis, mesenteric adenitis, Crohn's disease, sickle cell crisis, gall stones, pancreatitis, tonsillitis, otitis media, acute hapatitis, acute porphyria, intestinal bands, malrotation, ureteric calculi, urinary tract infection, pneumonia, peptic ulcer disease, psychogenic, Henoch-Schonlein purpura, intussusception, yersinia infection, obstructed inguinal hernia, contd.

13 torsion of testicle, omental infarction, renal vein thrombosis, acutehydronephrosis, primary peritonitis, salpingitis, ovarian cyst, ectopic tubalpregnancy, pyelonephritis, trauma, infective gastroenteritis, food poisoning, child abuse, attention seeking behavior, intestinal volvulus,choledochal cyst, cholangitis, foreign body, adhesions and small bowelobstruction, pica, ketoacidosis

14 Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. Coulier B, Tancredi MH, Ramboux A. Department of Diagnostic Radiology, Clinique St Luc, Rue St Luc 8, Bouge, Namur, Belgium.

15 The aim of this retrospective study was to emphasize the performances of spiral CT (HCT) and multidetector-row CT (MDCT) as very effective imaging modalities for the diagnosis of intestinal perforations caused by calcified alimentary foreign bodies. Eight sites of perforations of the ileum by ingested foreign bodies were found in seven patients--one patient presenting with two separate sites of perforation. The diagnosis was successfully made by HCT in four patients and MDCT in the remaining three. Involuntarily and generally unconsciously ingested chicken and fish bones were the implicated calcified foreign bodies. The acute clinical presentations were nonspecific, mimicking more common acute abdominal conditions.

16 A thickened intestinal segment (7/8 sites) with localized pneumoperitoneum (4/8 sites), surrounded by fatty infiltration (4/8 sites) and associated with already present or developing obstruction or subobstruction (5/7 patients) were the most common CT signs, but the definite diagnosis was clearly made by the identification of the calcified foreign bodies (7/7 patients). In each patient, this identification was only possible thanks to the scrupulous analysis of very thin overlapping reconstructions obtained not only in the perforation sites (6/8 sites), but also through the entire abdomen (2/8 sites). Our report emphasizes the high performances of CTA and MDCT in identifying intestinal perforation caused by calcified alimentary foreign bodies. Moreover, the high specificity of the CT diagnosis made it possible to avoid surgical exploration in three patients.

17 Acute abdomen in the elderly Sixty six percent of elderly patients had concomitant diseases, that were multiple in 63%. In this age group, the causes accounting for 71% of acute abdominal pain were biliopancreatic diseases (31.1%), intestinal adhesive obstruction (17.7%), complicated abdominal wall hernia (13.7%), and complications of peptic ulcer disease (8.9%). Sixty four percent required surgical treatment and, in almost 50% the surgical risk was classified in ASA III or IV, according to the American Society of Anesthesiology. Thirty one percent had postoperative complications. Compared with their younger counterparts, elderly patients required significantly (p<0.05) more admissions to intensive care units (2.7 and 24.2% respectively), more connections to mechanical ventilation (1.4 and 8.9% respectively) and longer hospital stays (5.4+/-7.4 and 12.4+/-10.9 days, respectively). In this series overall mortality was 6.7%, being 0.6% for young patients and 11.1% for the surgical group over 65 years old.

18 Understanding pain

19 Summary points Opt for safety and simplicity Measure and record pain regularly be proactive Choose evidence based interventions Trust patients and tailor treatment to their individual needs and allow them to have control Choose appropriate drug, route, and mode of delivery Educate staff and patients

20 Settings where pain is a problem After operations: inpatient; day surgery; wound dressing Medical illness: myocardial infarction; sickle cell crisis; renal colic Musculoskeletal disease: acute low back pain; rheumatoid arthritis Cancer Trauma Burns Childbirth

23 Causes of acute abdomen In first few years of life 1. Congenital abnormalities 2. Incarcerated inguinal hernia 3. Intussuception 4. Intestinal volvulus 5. GI perforation 6. NEC in preterm neonates

24 In older children 1.Trauma 2. Pancreatitis 3. Meckel s diverticulum 4. Primary peritonitis 5. Intestinal worm infestation In adolescents 1. Acute appendicitis 2. Cholecystitis (acalculous) 3. Testicular torsion 4. Rupture of ovarian cyst Non- surgical causes of abdominal pain 1. Hyperthyroidisin 2. Addison s disease 3. Diabetic ketoacidosis 4. Hypercalcemia 5. Lead poisoning 6. Porphyria

25 Investigations in a child with acute abdomen: 1. Abdominal X-Ray/Chest X-Ray erect Look for bowel obstruction calcification, free air and lower lobe pneumonia. Also soft tissue mass may be seen 2. Ultrasound of both pelvis and upper abdomen For hepatobiliary, renal and gynaecological pathology. 3. Complete blood count Increased in case of necrosis, bacterial infection, abscess 4. Peripheral smear for HUS, Sickle cell. 5. Urine examination for UTI, porphyria Additional investigations Serum Amylase/lipase for pancreatitis Blood cultures Beta HCG CT scan for abdomen Stool examination for worm infestation

26 Typical presenting clinical characteristics of appendicitis in infants and children Diagnosi s Age/S ex History Physical Examinat ion Lab Analysis Radiology (Abdomen ) Appendic itis Peak: years M:F=3 :2 Periumbi lical pain (early) followed by vomiting and localized right lower quadrant pain. - Fever >100.5 degree F. - Localized right lower quadrant peritonitis Increase d WBC (> 10000/c umm) X-Ray - Concave curvature of spine to the right. - Presence of faecolith in 5 10 % USG - Pericolic /appendice a fluid and/or edema.

27 Estimated Fetal Exposure From Some Common Radiologic Procedures Procedure Fetal Exposure Chest radiograph (2 views) Abdominal film (single view) Intravenous pyelography Hip film (single view) Mammography Barium enema or small bowel series CT scan head or chest CT scan abdomen and lumbar spine CT pelvimetry mrad 100 mrad >1 rad* 200 mrad 7-20 mrad 2-4 rad <1 rad 3.5 rad 250 mrad

28 Thank You

The Acute Abdomen. Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital

The Acute Abdomen. Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital The Acute Abdomen Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital Causes of the Acute Abdomen Hemorrhage in the GI tract Blood vessel GU tract Perforation of the GI tract Ulcer Infection